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Fire Investigation Report Request

2. This form constitutes an official request for information under the New York State Freedom of Infomation Law.

4. Name of Requester*

5. Company Name*

7. Company Address*

   Street/City/State/Zip

8. Company Phone*

10. Email*

11. Company Fax Number

13. Date of Request*
    Date of Request

    Date of Request

14. Attachments

    Please attach your signed request on company letterhead.

18. Property Owner Name*

20. Incident Date ? Time*
    Incident Date ? Time

    Incident Date ? Time

21. Incident Address*

23. Insurance Company Name*

24. Insurance Company Address*

    Street/City/State/Zip

26. Claim Number

27. Insurance Company Phone

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field